Uterine transplantation is the final gynaecological frontier

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The successful transplantation of a uterus represents the last major surgical goal in the field of reproductive gynaecology. This feat has recently been achieved by a team at the University of Gothenburg in Sweden.

The 36-year-old patient was born with a condition called Mayer-Rokitansky-Küster-Hauser (MRKH) Syndrome. The condition occurs in one out of every 4,000 babies, and presents as the absence of a uterus and sometimes a vagina. The absence of a kidney may also be a feature of this condition.

MRKH Syndrome usually manifests in late puberty. Because these women appear outwardly normal, the absence of a vagina or uterus will only be suspected after examination, and subsequently confirmed by an MRI. The psychological burden on a young woman discovering that she has this condition is immense, which is why I personally am delighted that this milestone has been accomplished.

The feat is really quite extraordinary when one considers the technical details involved. Transplanting a uterus is not as straightforward as transplanting a kidney or a liver, which requires only that the organ has an adequate blood supply and is ‘plugged’ into the relevant nearby organs. Those organs do not need to radically increase in size or change much in order to function as intended.

A uterus is a far more dynamic organ. In its non-pregnant state, the uterus is the size of a pear, weighs roughly 50 grams and has an inconsequential blood supply. In the pregnant state, however, it reaches a size of 900 grams and has a blood supply equivalent to 20% of the blood pumped by the heart per minute. The pregnant uterus also requires the growth of new blood vessels throughout early pregnancy, which will themselves grow with the pregnancy.

The transplanted uterus has to be anchored securely to the pelvic tissues, without damaging nearby blood vessels, nerves or the ureters. The most critical part of the surgery, the so-called ‘vascular anastomosis’, requires a very skilled vascular surgeon to join the blood vessels to supply the uterus with the major pelvic blood vessels. The potential risks of the surgery itself include haemorrhage, infection, injury to neighbouring organs, deep vein thrombosis (which can lead to lung clots) and other complications.

Infection risks will be considerably higher than normal, due to the anti-rejection drugs the patient must take for the lifetime of the organ. In the long-term these can cause health problems, including a slightly higher risk of cancer. Assuming that the patient may undergo hysterectomy once she has completed her family, she will not need to be on these drugs indefinitely.
Given all these risks, I believe the surgical team and their patient should be saluted for their determination, indefatigability and success. I look forward to the day that uterine transplants are as routine as those of a heart or kidney.